Monday, November 21, 2011

Modifier 57 using with E & M code

57 Modifier - Decision for surgery made within global surgical period

E/M services on the day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global surgery payment for the major surgery and, therefore, may be billed and paid separate

If E/M services occur on the day of surgery, the physician bills using modifier 57, not 25. The 57 modifier is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery.

Moreover, when the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure.


An E/M service on the same day of or on the day before a procedure with a 90- day global surgical period is covered if the physician uses CPT modifier 57 to indicate that the service resulted in the decision to perform the procedure.

Payment may not be made for an E/M service billed with the 57 modifier if it was provided on the day of or the day before a procedure with a zero- or 10-day global surgical period.


E/M Service Resulting in the Initial Decision to Perform Surgery

E/M services on the day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global surgery payment for the major surgery. Therefore, these services may be billed and paid separately.

In addition to the CPT E/M code, modifier “-57” (Decision for surgery) is used to identify a visit that results in the initial decision to perform surgery.

The modifier “-57” is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. When the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and a visit or consultation is not billed in addition to the procedure. MACs may not pay for an E/M service billed with the CPT modifier “-57” if it was provided on the day of, or the day before, a procedure with a 000- or 010-day global surgical period.



Reimbursement Guidelines

An E/M service provided the day before or the day of a surgical procedure which resulted in the initial decision to perform surgery is eligible for separate reimbursement in addition to the global surgery allowance for the procedure code when all of the following criteria are met:

** The surgical procedure code is a major surgery (global period of 090 days).

** Modifier -57 is appended to the E/M code.

** The medical record documentation supports the use of modifier 57.

The submission of modifier -57 appended to a procedure code indicates that documentation is available in the patient’s records which will support that the E/M service resulted in the initial decision to perform the surgery, and that these records will be provided in a timely manner for review upon request.


Modifier -57 is not considered valid when the E/M service is associated with a minor surgical procedure (defined as having a 0 or 10 day global period). (CMS2 ) If an evaluation and management (E/M, E&M) service is billed with modifier 57 appended and is identified as related to a minor surgery procedure, the service will be denied as included in the global surgery package despite the use of the modifier. Modifier -57 should not be used when the E/M service was for the preoperative evaluation.


Coding Guidelines

“CPT Surgical Package Definition – By their very nature, the services to any patient are variable. The CPT codes that represent a readily identifiable surgical procedure thereby include, on a procedureby-procedure basis, a variety of services. In defining the specific services “included” in a given CPT surgical code, the following services are always included in addition to the operation per se:…Subsequent to the decision for surgery, one related Evaluation and Management (E/M) encounter on the date immediately prior to or on the date of procedure (including history and physical)…” (AMA1 )

“If a procedure has a global period of 090 days, it is defined as a major surgical procedure. If an E&M is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with modifier 57. Other preoperative E&M services on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not separately reportable.”

URMC Compliance Office Guidance for Use of Modifier 57 Decision for Surgery

Modifier 57 Decision for Surgery: add Modifier 57 to the appropriate level of E/M service provided on the day before or day of surgery, in which the initial decision is made to perform major surgery. Major surgery includes all surgical procedures assigned a 90-day global surgery period. The global surgery policy includes the E/M service provided on the day before or the day of the major surgery procedures unless the E/M service resulted in the decision to perform surgery. CPT codes for use with modifier -57 are 92002 to 92014 and 99201- 99499, (including ED codes 99281-99285). Reference guide to the use of Modifier -57 Modifier -57  Evaluation and Management (E/M) Documented E/M meets criteria specified in code Initial decision to perform the surgical procedure on same day or another day (E/M day before or day of  major surgery that resulted in initial decision to  perform the surgical procedure)

The following services are not included in the global surgical payment. These services may be billed and paid for separately:

• Initial consultation or evaluation of the problem by the surgeon to determine the need for major surgeries. This is billed separately using the modifier -57 (Decision for Surgery). This visit may be billed separate surgical procedures:


UHC Guidelines

The following services are not included in the global surgical payment. These services may be billed and paid for separately:

** Initial consultation or evaluation of the problem by the surgeon to determine the need for major surgeries. This is billed separately using the modifier -57 (Decision for Surgery). This visit may be billed separately only for major surgical procedures;

Note: The initial evaluation for minor surgical procedures and endoscopies is always included in the global surgery package. Visits by the same physician on the same day as a minor surgery or endoscopy are included in the global package, unless a significant, separately identifiable service is also performed.

Modifier -25 is used to bill a separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure.

** Services of other physicians related to the surgery, except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record;

** Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;

** Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery;

** Diagnostic tests and procedures, including diagnostic radiological procedures;

** Clearly distinct surgical procedures that occur during the post-operative period which are not re-operations or treatment for complications;

Note: A new post-operative period begins with the subsequent procedure. This includes procedures done in two or more parts for which the decision to stage the procedure is made prospectively or at the time of the first procedure.


In addition to the E/M code, modifier “-57” (Decision for surgery) is used to identify a visit that results in the initial decision to perform surgery. The modifier “-57” is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. Where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and a visit or consultation is not billed in addition to the procedure. Carriers/MACs may not pay for an E/M service billed with the modifier “-57” if it was provided on the day of or the day before a procedure with a 0 or 10 day global surgical period.

Example usage for Modifier 57

Modifier -57: An E&M service that resulted in the initial decision to perform surgery.

• May be appended to E&M services that resulted in the initial decision to perform a surgery.

Example

Initial office visit for 65-year old female who suffered severe ankle trauma in a fall. Patient was found to have a fracture of the left malleoli. Surgical repair and pinning was recommended.

Incomplete Billing Complete Billing Diagnosis 824.8 (Fracture of ankle, unspecified, closed)

824.8 (Fracture of ankle, unspecified, closed)

Code 99204 Office or other outpatient visit for the E&M of a new patient

27814 Open treatment of bimalleolar ankle fracture (e.g. lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli), includes internal fixation, when performed.

99204-57

27814 Note: Anthem Blue Cross commonly sees incomplete coding examples for modifier-59 as indicated above from the following specialties: Physical Therapy, Chiropractic and Acupuncture. Modifier -59: Distinct procedural service.


Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure


Modifier “-25” (Significant, separately identifiable E/M service by the same physician on the same day of the procedure), indicates that the patient’s condition required a significant, separately identifiable E/M service beyond the usual pre-operative and post-operative care associated with the procedure or service.

Use modifier “-25” with the appropriate level of E/M service.

• Use modifiers “-24” (Unrelated E/M service by the same physician during a post-operative period) and “-25” when a significant, separately identifiable E/M service on the day of a procedure falls within the post-operative period of another unrelated procedure.

Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified non-physician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.

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